A standard is defined as something established by authority, custom, or general consent. Clearly that does not exist for
BACKGROUND CONTEXT.
Young patients have been reported to have a higher risk of revision following total hip arthroplasty than older cohorts. This was attributed to the higher activity level which led to increased wear, osteolysis, and component fracture. We prospectively assessed the clinical results, wear and osteolysis, the incidence of squeaking, and the survivorship of
While crosslinked polyethylene has reduced the rate of wear and osteolysis in THA, osteolysis still occurs and taper-corrosion induced wear has become recognised as an increasing problem especially when larger diameter metal bearings are used. Long-term follow up studies of newer polyethylene bearings continue to lag those of ceramic-on-ceramic bearings by several years. Ceramic-on-ceramic (CoC) bearing surfaces have consistently demonstrated reliable clinical results with when coupled with appropriated designed femoral stems and acetabular shells and have been shown to exhibit virtually no risk of adverse biologic reaction. Further, CoC bearings have not been associated with corrosion-induced adverse tissue reactions that occur with metal taper junctions. Revisions for squeaking have been associated with specific designs and materials, including the use of a titanium elevated metal rim on the acetabular side, and more flexible femoral components made of a beta-titanium alloy (TMZF) which had thin necks and relatively small tapers. Multiple clinical studies document excellent long-term survival of CoC bearing couples in young patients with revision for any reason as the primary endpoint. Our own experience with 341 hips in patients under 50 with 2–15 years and average 9.1-year follow up demonstrates a 95% overall survivorship (revision for any reason) at 13 years. CoC bearings continue to show excellent durability in young, high demand patients with an absence of osteolysis in any case. CoC bearings continue to represent an excellent alternative to bearing couples containing polyethylene.
A
The use of hard-on-hard bearings, including ceramics peaked in the mid 2000's and has seen rapid decline since that time. Ceramics are not new to the market place but have had a 40 year history outside the U.S. The basis for renewed enthusiasm for ceramics included improved manufacturing, improved taper tolerances, higher strength, and lower wear. In spite of the major improvements concerns have been expressed with new generation ceramics by the experts and thought leaders in the field. The major concerns included complications related to modularity, continued problems with fracture and consequences of fracture, limited surgical options, and squeaking and impingement. The conclusion of one review article was that “although ceramics show promise as a lower wear articulation, manufacturing and design modifications and improvements will continue in an attempt to address the substantial concerns that persist”. Modifications have indeed occurred. The question is rather all of these concerns have been addressed and the answer is no. One proposed solution was a hybrid material of Alumina and Zirconia (Delta Ceramic). The advantages included higher strength, lower wear, more options and possibly less squeaking. Unfortunately the modest material improvements did not begin to overcome the obstacles to adopting this technology. High on this list is the problem with cost with the current health care environment unwilling to pay for expensive new technology that does not have proven value. A 2nd major issue is new technology must account for variability in surgeon performance in maximising margin for error. The medical legal environment is unforgiving of failure of new unproven options. Most of the old issues with ceramics have not been completely resolved. Delta
The leading cause for total hip arthroplasty (THA) revision remains aseptic loosening due to bearing wear. The younger and more active patients currently undergoing arthroplasty present unprecedented demands on THA-bearings. Ceramic-on-ceramic (CoC) bearings have consistently shown the lowest wear rates. The recent advances, especially in alumina CoC bearings, have solved many past problems and produced preferable results in vitro. Alumina ceramics are extremely hard, scratch resistant, biocompatible, offer a low coefficient of friction, superior lubrication and lower wear rates in comparison to other bearings in THA. The major disadvantage of ceramics used to be fracture. The new generation of alumina ceramics, has reduced the risk of ball fracture to 0.03–0.05%. The risk for liner fracture is even lower. Assuming an impingement-free component implantation, CoC bearings have major advantages over other bearing combinations. Due to the superior hardness, CoC bearings produce less third body wear and are virtually impervious to damage from instruments during the implantation process. A complication specific to CoC bearings is squeaking. Squeaking occurs if the friction in the joint articulation is sufficient to excite vibrations to audible magnitudes (due to loss of lubrication). The high range of reported squeaking (0.45% to 10.7%) highlights the importance of correct implant position. If a correct implant position can be guaranteed, then squeaking is rare and without clinical significance. The improved tribology and presumable resulting implant longevity make CoC the bearing of choice for young and active patients. Especially the alumina matrix (Biolox delta) offers increased burst strength and greater fracture toughness.
Properly designed ceramic-on-ceramic total hip arthroplasty has consistently shown excellent clinical outcomes without the problems associated with crosslinked polyethylene bearings such as liner dissociation, debris associated osteolysis, polyethylene fracture, clinically measurable wear, and taper-corrosion associated adverse tissue reaction when metal heads are used. The recognition of these results has been affected by the confusion with the poorer results of designs with elevated metal rims especially when coupled with the use of femoral components made of beta-titanium alloys. Our clinical experience, now at 18 years, with flush mounted liners and Ti-Al6-V4 stem and cup alloy demonstrate consistently excellent outcomes without osteolysis or ALTR. Ceramic-Ceramic THA remains the gold standard for the young active patient.
INTRODUCTION. Young patients (< 50 years old) have been reported to have a higher risk of revision following total hip arthroplasty (THA) than older patient cohorts, possibly to due higher activity, a higher incidence of deformity and greater probability of prior surgery. Ceramic-on-ceramic bearing surfaces have been proposed for use in young and active individuals due to their low wear, low risk of adverse biologic reaction, and long-term survivorship. We assessed the clinical results and long-term survivorship of uncemented ceramic-on-ceramic THA in a young patient population. METHODS. Between August 1999 and December 2007, 220 total hip arthroplasties in 191 patients under 50 years of age at the time of surgery were performed using alumina ceramic-ceramic bearings as part of a prospective, non-randomized study. All patients received uncemented acetabular components with flush-mounted acetabular liners using an 18 degree taper, and uncemented femoral components. The average patient age at the time of surgery was 42.1 ±7.2 years (range: 17.4 years to 49.9 years), and the average time to follow-up was 10.1 ±2.4 years (range: 4.2 years to 15.2 years). We evaluated implant-related complications and performed Kaplan-Meier analyses to determine survivorship of the THA components with revision for any reason as the endpoint. RESULTS. There were no dislocations or failures due to osteolysis or aseptic loosening. There was one patient death not related to the THA procedure. Through 15-years, the Kaplan-Meier survivorship of all components was 94.9% (CI: ±8.0) with 8 revisions (3.6%) of either the cup, the stem, or both. For the acetabular component, the 15-year survivorship was 97.0% (CI: ±6.1) and included 4 revisions (1.8%), and 98.1% (CI: ±1.9) for the femoral component including 4 revisions (1.8%). One patient had both the femoral and acetabular components revised. There were two liner fractures (0.59%) and one head fracture (0.3%), two of which were sustained as a result of a fall from significant height. There were three failures of osseointegration (1.3%), and one acetabular component dislodged (0.4%) immediately following surgery. Two patients reported non-reproducible squeaking. One hip was revised at an outside institution for unknown reasons. Using the National Institutes for Health and Clinical Excellence (NICE) guidelines, our results are well within the 1% per year acceptable failure rate for this young patient population (acetabular components: 0.1% per year, femoral components: 0.1% per year, all revisions: 0.2% per year). From our experience, ceramic-on-ceramic THA in patients less than 50 years of age is very reliable with a low revision rate and absence of wear-related osteolysis. Component fracture typically occurs with high-energy trauma, and squeaking occurrence is rare in the flush-mounted
While total hip arthroplasty (THA) has been shown successful at relieving pain and improving function in patients with coxarthrosis, wear and instability remain leading causes for revision surgery. Highly crosslinked polyethylene (HXPE) has significantly reduced wear and osteolysis but volumetric wear associated with the use of larger diameter ball heads may be an issue in the long-term. Finally, concerns with femoral taper corrosion have increased the utilization of
Aim. Alumina
Objectives. Total hip replacement is increasingly being conducted in younger and more active patients, so surgeons often use bearing surfaces with improved wear characteristics, such as
Introduction. Long term results of Total Hip Arthroplasty (THA) are affected by wear of articulation.
Revision is a key negative outcome of joint replacements. The purpose of this abstract is to present revision risk curves for hip and knee replacements based on the most recently available national data sources. Having a better understanding of determinants of revision risk can help inform clinical and health care system improvements. We explored revision risk of primary joint replacement stratified by key clinical, prosthesis, and surgeon-level factors using data from three databases managed by CIHI: the Canadian Joint Replacement Registry (CJRR), the Discharge Abstract Database, and the National Ambulatory Care Reporting System. To investigate early revisions, we used Kaplan-Meier analysis stratified by demographic factors to determine the risk of revision within up to five years of primary surgery. This analysis identified the primary cohort from the CJRR from April 1, 2012 to March 31, 2017 and was limited to mandatory reporting provinces (British Columbia, Manitoba and Ontario) to ensure maximal coverage of prosthesis information. Bearing surface was obtained from the International Prosthesis Library maintained by the International Consortium of Orthopaedic Registries (ICOR) and the International Society of Arthroplasty Registers (ISAR). The total revision risk cohort contained 283,620 primary surgeries, of which 5,765 (2%) had at least one revision. For total hip arthroplasties, revision risk at the end of the follow-up period did not differ by age, by sex or across bearing surface (metal on cross-linked polyethylene [XLPE],
Introduction. Alumina
Due to issues related to osteolysis which became increasingly evident in the 1990's, approaches to combat wear focused upon either improving ultra-high molecular grade polyethylene or to abandon it and employ alternative bearings: metal upon metal or
Introduction. Infection remains a serious complication following primary total hip arthroplasty (THA). Many factors including primary diagnosis, comorbidities and duration of procedure are known to influence the rate of infection. Although the association between patient and surgical factors is increasingly well understood, little is known about the role of the prosthesis. This analysis from the Australian Registry (AOANJRR) was undertaken to determine if revision for infection varied depending on the type of bearing surface used. Methods. Three different bearing surfaces,
Background. Total Hip Arthroplasty (THA) using the Direct Anterior Approach (DAA) is a muscle sparing approach which promotes early mobilisation of patients. It is a technically challenging approach shown to have a high rate of complications, especially during the learning curve. Here we present the results of 157 cases of THA via a DAA on a standard theatre table, with a minimum of 6 months follow-up. Materials & Methods. The authors conducted a prospective study on a group of 149 consecutive patients undergoing 157 cementless primary THAs for coxarthrosis, 8 bilateral. The same surgical technique was used in all patients, performed by the senior author WLW at a single centre. The average age of the patients at time of surgery was 69 years, 78% were female and 57% were right sided. All implants were uncemented, with bearings being
This prospective randomised controlled trial aims to compare the clinical and radiological outcomes of
Purpose. This prospective randomised controlled trial aims to compare the clinical and radiological outcomes of